Nerve Injuries of the Upper Limb

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Nerve Injuries of the Upper Limb

• Dr. Zeenat Zaidi

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• Upper limb is supplied by
  the branches of the brachial
  plexus, formed by the
  ventral rami
  of the spinal
  nerves C5, 6, 7, 8, and T1
• Since the spinal nerves are mixed nerves carrying
  sensory, motor and
  autonomic fibers, their injuries result in
  sensory, motor and autonomic disturbances

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Symptoms Signs of Peripheral Nerve Injury

• Depend on the site and extent of the lesion
• Motor changes The innervated muscles become
  paralyzed. The reflexes in which the muscles
  participate are lost
• Sensory changes Loss of cutaneous sensibility
  over the area exclusively supplied by the nerve
• Trophic changes Due to interruption of
  postganglionic sympathetic fibers
• There is loss of vascular control the skin at
  first becomes red hot. Later becomes blue and
  colder than normal. The nail growth becomes
  retarded
• The sweat glands cease to produce sweat and the
  skin becomes dry and scaly

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Upper Limb Tendon Reflexes

• Biceps brachii reflex C5, 6 (flexion of elbow
  joint by tapping the tendon of biceps muscle)
• Triceps brachii reflex C6, 7, 8 (extension of
  elbow joint by tapping the tendon of triceps
  muscle)
• Supinator (brachioradialis) reflex C5, 6, 7
  (supination of radioulnar joint by tapping the
  tendon of brachioradialis muscle)

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• A spinal nerve may get injured
• at the level of its roots within the vertebral
  canal
• at the level of its passage through the
  intervertebral foramen
• At any level in its peripheral course
• Injuries 1 2 may result due to
• Fracture of the vertebra
• Narrowing of intervertebral foramina
• Herniation of the intervertebral disc
• Degeneration of the intervertebral disc

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Brachial plexus injuries

• May involve the roots, trunks, divisions, cords
  branches
• Supraclavicular injuries involve the roots and
  the trunks, infraclavicular injuries will affect
  the divisions and cords
• Result due to
• Compression
• Traction
• Stab wounds
• Symptoms depend on the site of injury
  involvement of nerve fibers

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Brachial plexus injuries

• Are of two types
• Upper lesions usually involving C5 C6
• Lower lesions usually involving (C8), T1

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Upper Lesions of the Brachial Plexus(Erb-Duchenn
e Palsy)

• These are usually the result of traction
  tearing of the 5th and 6th root of the brachial
  plexus
• This may occur
• In infants during a difficult delivery
• In adults following a fall on or a blow to the
  shoulder.
• It involves the
• Nerve to sublavius
• Suprascapular nerve
• Axillary nerve
• Musculocutaneous nerve

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• The muscles affected are
• Abductors (supraspinatus deltoid) and lateral
  rotators (Infraspinatus teres minor) of the
  shoulder
• Subclavius, biceps, brachialis coracobrachialis
• Thus
• The limb hangs limply by the side, and is
  medially rotated
• The forearm is pronated and extended
• There is loss of sensation down the lateral side
  of the arm the forearm
• Another name for this lesion is 'porters tip'

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Lower Lesions of the Brachial Plexus (Klumpke
Palsy)

• These are usually caused by excessive abduction
  of the arm as a result of
• Someone clutching for an object when falling from
  a height
• Difficult delivery in which babys upper limb is
  pulled excessively.
• Result of malignant metastases from the lungs in
  the lower deep cervical lymph nodes
• A cervical rib

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• Usually the lowest root (T1) of the brachial
  plexus is involved
• The fibers from this segment of the spinal cord
  supply the small muscles of the hand (interossei
  and lumbricals).
• Paralysis and wasting of small muscles of hand
  occurs
• There is also sensory loss along the medial side
  of the forearm, hand and medial 2 fingers
• Often associated with Horners syndrome (drooping
  of upper eyelid constricted pupil) due to
  traction of sympathetic fibers

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• The hand has a clawed appearance due to
• Hyperextension of the metacarpophalangeal joints
  (the extensor digitorum is unopposed by the
  lumbricals and interossei and extends the
  metacarpophalangeal joints).
• Flexion of the interphalangeal joints (the flexor
  digitorum superficialis and profundus are
  unopposed by the lumbricals and interossei, the
  middle and terminal phalanges are flexed).

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Long Thoracic Nerve Lesion(Nerve to Serratus
Anterior)

• This nerve may be injured by
• Blows or pressure in the posterior triangle of
  the neck
• During a radical mastectomy surgical procedure.
• The serratus anterior muscle
• Pulls the medial border of the scapula to the
  posterior thoracic wall and stabilizes it there.
• Rotates scapula during the abduction of arm above
  a right angle

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• The patient shows difficulty in raising the arm
  above the head
• If patient is asked to push against a wall, the
  medial border of the scapula will be pushed away
  from the thoracic wall and protrude like a wing,
  on the side of the lesion. 'winged scapula'.

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Axillary Nerve Lesion

• Axillary nerve may get injured
• Due to downward dislocation of humeral head in
  shoulder dislocation
• Fracture of the surgical neck of humerus
• Deltoid and teres minor muscles become paralyzed
• Abduction of the shoulder is impaired. The
  paralyzed deltoid wastes rapidly (loss of rounded
  contour of the shoulder)
• Loss of sensation over the lower half of deltoid
  muscle

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Radial Nerve

• The radial nerve is commonly damaged
• in the axilla
• in the radial groove
• Injury to the deep branch (in the supinator
  tunnel)
• Injury to the superficial branch

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Radial Nerve Injury in the Axilla

• In the axilla the nerve may be injured by
• Pressure of the upper end of badly fitting crutch
  pressing up in to the armpit (crutch palsy)
• The drunkard falling asleep with his arm over the
  back of a chair (saturday night palsy).
• Fractures or dislocations of the upper end of the
  humerus

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• Motor
• Triceps, anconeus and long extensor of the wrist
  are paralysed.
• The patient is unable to extend the elbow joint,
  wrist joint and fingers.
• Wrist drop or flexion of the wrist occurs as a
  result of the unopposed flexor muscles of the
  wrist.
• This is a very disabling injury, since a person
  can't flex the fingers strongly for gripping an
  object with the wrist fully flexed.
• The brachioradialis and supinator muscles are
  paralyzed, but supination can still be performed
  due to intact biceps brachii.

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• Sensory Due to the overlap of sensory
  innervation by adjacent median ulnar nerves,
  the area of total anaesthesia is relatively
  small, overlying the first dorsal interosseous
  muscle (between the 1st and 2nd metacarpal bones)

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Radial Nerve Injury in the Radial Groove

• The most common lesion of the radial nerve
  resulting because of the
• Fracture of the shaft of humerus
• Callus formation
• Pressure on the back of the arm on the edge of
  the operating table in an unconscious patient
• Prolonged application of tourniquet.

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• The injury to radial nerve occurs most commonly
  in the distal part of the groove beyond the
  origin of the nerve to the triceps anconeus (so
  that extension of the elbow is possible), and
  beyond the origin of the cutaneous nerves
• Motor The long extensors of the forearm are
  paralyzed and this will result in a "wrist drop".
  
• Sensory Loss of sensation from small area
  overlying the first dorsal interosseous muscle

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Injury to the Deep Branch of the Radial Nerve

• It may be damaged in fractures of the proximal
  end of the radius or during dislocation of the
  radial head.
• Motor.
• Intact forearm extension and flexion with intact
  hand extension. Only weakness of finger
  extensors.
• Nerve supply to the supinator and extensor carpi
  radialis longus will be undamaged and because the
  later muscle is powerful it will keep the wrist
  joint extended and wrist drop will not occur.
• Sensory There will be no sensory loss since this
  is a motor nerve.

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Injury to the Superficial Branch of the Radial
Nerve

• It may be damaged as a result of stab injury, or
  pressure from handcuffs tight bangles
• Motor There will be no motor loss since this is
  a sensory nerve.
• Sensory There is a small loss of sensation over
  the dorsal surface of the hand and the dorsal
  surfaces of the roots of the lateral three
  fingers

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Median Nerve Lesions

• Injury of median nerve at different levels cause
  different syndromes.
• The most serious disability of median nerve
  injuries is the
• Loss of opposition of the thumb. The delicate
  pincer-like action is not possible
• Loss of sensation from the thumb and lateral 2½
  fingers lateral ? of the palm

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Median Nerve Lesions

• Median nerve can be damaged
• In the elbow region
• At the wrist above the flexor retinaculum
• In the carpal tunnel

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Median Nerve Lesion in the Elbow Region

• Damaged in supracondylar fracture of humerus
• Muscles affected are
• Pronator muscles of the forearm
• All long flexors of the wrist and fingers except
  flexor carpi ulnaris and medial half of flexor
  digitorum profundus

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• Motor
• Loss of pronation. Hand is kept in supine
  position
• Wrist shows weak flexion, and ulnar deviation
• No flexion possible on the interphalangeal joints
  of the index and middle fingers
• Weak flexion of ring and little finger
• Thumb is adducted and laterally rotated, with
  loss of flexion of terminal phalanx and loss of
  opposition
• Wasting of thenar eminence
• Hand looks flattened and apelike, and presents
  an inability to flex the three most radial digits
  when asked to make a fist.

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• Sensory Loss of sensation from
• The radial side of the palm
• Palmer aspect of the lateral 3½ fingers
• Distal part of the dorsal surface of the lateral
  3½ fingers
• Trophic Changes
• Dry and scaly skin
• Easily cracking nails
• Atrophy of the pulp of the fingers

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Median Nerve Lesion at the Wrist

• Often injured by penetrating wounds (stab wounds
  or broken glass) of the forearm
• Motor Thenar muscles are paralyzed and atrophy
  in time so that the thenar eminence becomes
  flattened. Opposition and abduction of thumb are
  lost, and thumb and lateral two fingers are
  arrested in adduction and hyperextension
  position. Apelike hand
• Sensory trophic changes are the same as in the
  elbow region injuries

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Carpal Tunnel Syndrome

• Compression of median nerve in the carpal tunnel
• Motor Weak motor function of thumb, index
  middle finger
• Sensory Burning pain or pins and needles along
  the distribution of median nerve to lateral 3½
  fingers
• No sensory changes over the palm as the palmer
  cutaneous branch is given before the median nerve
  enters the carpal tunnel

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Ulnar Nerve Lesion

• Ulnar nerve can be damaged
• At the elbow, where it lies behind the medial
  epicondyle
• At the wrist, where it lies with the ulnar artery
  superficial to the flexor retinaculum

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Ulnar Nerve Lesion at the Elbow

• Often injured with fractures of the medial
  epicondyle
• Motor paralysis involves
• Flexor carpi ulnaris
• Medial half of flexor digitorum profundus
• Small muscles of the hands, except the muscles of
  thenar eminence and first two lumbricals.
• Adductor pollicis
• Sensory loss over the anterior posterior
  surfaces of the palm medial one and half finger
• Trophic changes because of loss of sympathetic
  control

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• Flexion of the wrist will result in abduction
• The thumb is abducted and extended with the
  distal phalanx flexed (difficulty in holding a
  piece of paper between thumb and index finger).
• The adduction and abduction of fingers is lost
  (difficulty in holding a piece of paper between
  fingers).
• The lateral two fingers are fully extended with a
  slight flexion of the distal phalanges.
• The medial two fingers are hyperextended at the
  metacarpophalangeal joints but flexed at the
  distal phalangeal joints.

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• Wasting of the hypothenar eminence
• The dorsum of the hand shows hollowing between
  the metacarpal bones
• The hand resembles a "claw" and is called a claw
  hand.
• The clawing becomes most obvious when the person
  is asked to straighten their fingers.

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Ulnar Nerve Lesion at the Wrist

• Commonly occur due to cuts and stab wounds
• Motor The small muscles of the hands are
  paralyzed, except the muscles of thenar eminence
  and first two lumbricals. The claw hand is more
  obvious as the flexor digitorum profundus is
  intact
• Sensory loss over the anterior surfaces of the
  palm and the anterior posterior surfaces of the
  medial one and half finger. (The posterior
  surface of the hand is spared as the posterior
  cutaneous branch arises above the level of wrist)
  

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